Making mentally ill defendants ready for trial

KERRVILLE, Texas -- The judge ascended the bench. He looked down at cafeteria-style tables marked "Prosecuting Attorney" and "Defense Attorney." To his left, two men sat in a box marked "Jury." The witness stand was marked "Witness."

"Sustained," proclaimed the judge, who wore a striped polo shirt, a thick goatee and a shock of greasy hair. He gave the gavel a sharp bang and waved it around, bringing the court to something resembling order, at least by the standards of a mock trial involving people who have been deemed mentally incompetent to participate in a real one.

In mental hospitals across the country, psychiatrists prepare criminal defendants for trial using innovative therapies such as this make-believe hearing, where patients and clinicians played the key courtroom roles. The process, they believe, reduces recidivism and protects public safety.

"Good treatment is your best security," said Michael Jumes, director of psychology services at the Kerrville State Hospital, where all 202 beds are filled with patients committed by the courts. "Medication alone can't do it."

But lawmakers in a number of states are scrambling to cut the cost of preparing mentally ill criminal defendants for trial. Dozens have authorized outpatient programs. Several, including Texas, are considering plans to provide treatment in jail.

A jail-based program allows defendants "to quickly receive treatment in a county jail from a team of highly qualified mental health professionals without waiting several weeks to be transported," said state Sen. Robert Duncan, a Lubbock Republican whose proposal for a pilot program has cleared the state Senate.

Courts order mental competency evaluations for about 60,000 criminal defendants a year, according to statistics cited by the National Judicial College, a nonprofit education group housed at the University of Nevada, Reno. About 20 percent are found unfit to stand trial.

The rules for restoring competency, as prescribed by the U.S. Supreme Court in 1960, require defendants to be able to consult with their lawyers "with a reasonable degree of rational understanding" and to comprehend the proceedings against them.

"The threshold for being competent to stand trial, the way most jurisdictions view it, is not very high," said William H. Fisher, a criminology professor at the University of Massachusetts-Lowell. By prescribing anti-psychotic medications, he added, some psychiatrists simply engage in "buffing people up."

Faced with long hospital waiting lists for such treatment, more than 30 states have authorized outpatient programs designed to expedite the process and save money, according to a report by Reena Kapoor, a psychiatry expert at Yale University of Medicine.

In Texas, according to a government budget analysis, state hospitals achieve a 75 percent success rate, at a cost of $421 for an average stay of 120 days. Outpatient treatment, at a reduced cost of $106 per day, has produced a success rate of 55 percent Charges were dropped against another 11 percent.

Now some lawmakers are looking to San Bernardino County, Calif., where officials have been operating a 20-bed pilot program known as "jail-based competency restoration." While the program has reported only a 45 percent success rate, with 19 of 42 patients restored to competency, California state budget analysts noted $70,000 in cost savings per patient as a success.

In Texas, the state Legislature has advanced bills to create a similar program. In Colorado, the Department of Human Services has sought funding for its own jail-based treatment.

Advocates for the mentally ill have spoken out against the proposals.

"Jail is not a therapeutic environment," said Katharine Ligon, a health care analyst at the nonprofit Center for Public Policy Priorities, testifying against the pilot program proposal. Jails, she argued, lack the training, resources and will to provide proper care.

Even patients who have been treated in hospitals often regress when they return to jail to await a court hearing, experts say.

"The downside to treating them in jail," said Christopher Slobogin, a professor of psychiatry and director of the criminal justice program at Vanderbilt University, "is that it's a jail."

Here at the Kerrville State Hospital, where the typical patient is a man in his forties who has been arrested on violent felony charges, "helping people gain the competency to stand trial and recover from their mental illness is a tall order," Dr. Jumes said. "And we try to strike that balance."

As the mock trial began, participants followed the script of a case involving a man who impersonated a police officer to steal a car. Dr. Janet Mueller, a psychologist who led the trial, said she was careful to avoid using scenarios resembling the participants' actual crimes, partly to protect their privacy and partly to avoid upsetting them.

As he listened to testimony, the patient playing the judge rocked in his seat, stared at the ceiling, pulled at his hair and briefly rested his head on the desk. At one point, he asked whether the district attorney needed to be sworn in.

In the end, the two-man jury delivered a split verdict. The judge asked to be reminded of the charges. Then he spoke up.

"Well, I got something," the judge said. "If he's so not guilty, why don't they take his fingerprints?"